1. C HVH BEHAVIOR FORUM APRIL 22, 2014 PRESENTED BY : R ENEE N ORDSTROM, MHC & M AURA P IEPER, MSW http://www.youtube.com/watch?v=YyZ9b4My6N U&feature=em-share_video_user

2. R ECAP FROM LAST B EHAVIOR F ORUM A UG. 19, 2 O 13 Topics discussed: 1. Changes in population- younger, more psych, more substance abuse 2. Training – need more in depth, more frequent 3. Activities – need more individualized, more staff 4. Mental Health – more complex psych dx, insurance issues Happenings since last meeting: 1. Martinsburg VAMC tour 2. Mental Health Summit 3. NCCDP classes 4. Mental Health First Aid classes 5. Alzheimer’s Assoc. Caregivers Support Group 6. Culture change group re- established

3. O UR G OAL TO DECREASE BEHAVIOR PROBLEMS AND IMPROVE THE DAILY LIVES OF THE RESIDENTS

4. Resident’s quality of life is directly affected by their moods; and their moods are usually identified by their behaviors

5. T ODAY ’ S T OPICS F OR D ISCUSSION : 1. P SYCH /B EHAVIOR RELATED FACILITY D ATA & C HALLENGES 2. C ULTURE CHANGE AND BEHAVIORS 3. W HAT ARE WE DOING TO MEET OUR GOAL ? 4. W HAT TOOLS / RESOURCES DO WE CONTINUE TO NEED ?

6. T HE NUMBER OF VA USERS WITH A MENTAL ILLNESS INCREASED BY 45% BETWEEN 2005 AND 2012

7. P SYCHOACTIVE MEDICATION USAGE STATISTICS SNF Antipsychotic usageAL Antipsychotic usage 1 st qtr 2012 – 28.7%1 st qtr 2012 – 15.4% 1 st qtr 2013 – 29.6%1 st qtr 2013 – 12.7% 1 st qtr 2014 – 22.0% 1 st qtr 2014 – 8.6% SNF Antidepressant usageAL Antidepressant usage 1 st qtr 2012 – 61.9%1 st qtr 2012 – 48.5% 1 st qtr 2013 – 68.5%1 st qtr 2013 – 49.3% 1 st qtr 2014 – 67.2%1 st qtr 2014 – 47.7%

8. ALTERCATIONS AUG ‘13 SEPT ‘13 OCT ‘13 NOV ‘13 DEC ‘13 JAN ‘14 FEB ‘14 MAR ‘14 VERBAL ALTERCATIONS: RESIDENT ON RESIDENT 01111000 PHYSICAL ALTERCATIONS: RESIDENT ON RESIDENT 00110020 Altercation w/Injury 0 0 0 1* 0 0 0 0 Altercation w/o Injury 0 0 1 0 0 0 2 0 Altercation involving resident with Dementia 0 0 1 0 0 0 2** 0 PHYSICAL ALTERCATIONS: RESIDENT ON STAFF 00001110 Altercation w/Injury 0 0 0 0 0 0 0 0 Altercation w/o Injury 0 0 0 0 1 1 1 0 Altercation involving resident with Dementia 0 0 0 0 1** 1 0 TOTAL # ALTERCATIONS 01222130 *Resident hurt own hand when attempted to hit other resident, missed, and hit wall. **3 incidents of physical altercation involved the same resident with dementia. B EST P RACTICES

9. G ROUP E XERCISE T IME !!!! After you complete the exercise ask yourself these questions: 1. How did it make you feel when you were the resident? 2. How did it make you feel when you were the one talking to the resident? 3. What can you take from this exercise? 4. Thoughts, feedback, discuss!!!

10. P SYCHIATRIC CARE OF OUR RESIDENTS MedOptions Psychologist 2x/week Possible vendorization of MedOptions to see VA psych patients who are not appropriate for Telemental Crisis intervention training for all 1C staff Barriers to psychiatric care due to insurance Barriers to psychiatric inpatient transfer due to Dementia as primary dx Only one psychiatric medication provider for both AL & SNF No VA psychiatrist on site at CBOC GDR requirements Delay in treatment issues(appt times, lack of second MD availability) ProgressChallenges

11. ADMISSIONS SNAPSHOT Questions for discussion: 1. Why the increase in younger veterans? 2. Why the increase in applicants with psych issues? 3. How can we change if the population is changing? 4. Is our criteria for admission truly conducive to our services? 5. Thoughts, feedback, discuss!!! Current applicants (60year old, SNF, 1C) Alzheimer’s, anxiety/bipolar disorder. Aggressive at home with wife, so she admitted him to an AL facility, then sent to ER same day due to becoming combative with staff, assaulting numerous employees, currently on 1:1, hospital recommending psych facility (68year old, SNF) 100%SC for Schizophrenia, admitted to psych unit due to thoughts of hurting others he believes are stealing from him, has history of altercations at other nursing homes, police involved after trying to strike nurses, paraplegic in wheelchair (57year old, SNF) Aphasic, paranoia, outbursts, past criminal record for drug distribution, theft, robbery with a deadly weapon, recurrent CVAs due to drug use (57year old, AL) Positive Mental Illness ID Screen, left side upper and lower paralysis, social worker having difficulty because veteran refuses to do anything for himself (58year old, SNF) Previously denied to AL due to criminal charges, psych admissions for suicidal ideation, intoxication, alcohol abuse current(1-2pints liquor/day), previously in rehab at Baltimore and Perry Point, no longer mentally capable of completing alcohol rehab, homeless, no Medicare, no bank accounts

12. A DMISSIONS SNAPSHOT It's estimated by the year 2020, nearly 12 million people will need long- term care, and this number is sure to grow with the aging baby boomer population Non-Denials (67year old, AL) – History of assault charges 1992-2008, Alcoholism, alcohol-related admissions to Martinsburg, no longer mentally capable of completing rehab Denials (62year old) – drug charges 2013 (89year old) – psychiatric issues (53year old) – failed criminal background (66year old) – psychiatric issues (61year old) – psychiatric issues (76year old) – alcohol, psychiatric issues (57year old) – psychiatric issues

13. H OW IS OUR CHANGING POPULATION ( BABY BOOMER VETS ) CHANGING HOW WE CARE FOR THEM ? AMONG PEOPLE IN THEIR 40S, ONLY 10 PERCENT HAVE SECURED AN INSURANCE PLAN Boomers are changing long-term health care by not preparing for it while it's still affordable. Since the cost of long-term care increases with age, purchasing insurance for it is most affordable before retirement -- a time when boomers aren't typically focused on making that purchase. AMONG PEOPLE IN THEIR 40S, ONLY 10 PERCENT HAVE SECURED AN INSURANCE PLAN. If more people are unprepared for the costs associated with aging, funds in need-based programs such as Medicaid are expected to be depleted in coming years.

14. C ULTURE C HANGE AND B EHAVIORS What are some of the benefits from Culture Change?

15. C ULTURE C HANGE Questions for discussion: 1. How will culture change curb behaviors? 2. Why do some people resist culture change? 3. How can we change their perception? 4. How can we make culture change contagious? 5. Thoughts, feedback, discussion!!! Resident Benefits: reduces loneliness, helplessness and boredom; improves physical and mental health (e.g. reduces depression and behavioral problems); reduces unanticipated weight loss; reduces mortality Staffing Benefits: reduces employee turnover; reduces overtime; reduces workers’ compensation claims/costs Additional Benefits: significantly improves employee, resident, and family satisfaction; increases involvement with the outside community including clubs, students, religious organizations, children, etc

16. I NSTITUTIONS TEND TO PRESERVE THE PROBLEMS FOR WHICH THEY ARE THE SOLUTION -C LAY S HIRKY https://www.youtube.com/watch?v=SUifqX11ZDY

17. G ROUP E XERCISE T IME !!!!

18. W HAT ARE WE DOING TO MEET OUR GOAL ? Culture Change Training Ongoing collaboration with other facilities

19. W HAT TOOLS / RESOURCES DO WE CONTINUE TO NEED ? Turn a designated unit into a locked dementia and/or psychiatric unit? Do we need a substance abuse rehab unit? Better collaboration with hospitals re: psych admissions? Use Culture Change to help reduce behavior problems? More psychiatric medication management staff? CNA/GNA Leader program? More staff accountability? EMPOWER AND EDUCATE STAFF AND YOU WILL SEE A CHANGE!!!

20. R EFERENCES English, Marianne. "5 Ways Baby Boomers Are Changing Long-term Care" 17 May 2011. HowStuffWorks.com. 16 April 2014. Eilier,Victoria(2013,September)Welcome to the Perry Point Va Medical Center. Mental Health Summit. Lecture conducted from Donaldson Brown Center at Port Deposit, Maryland.